INQUEST INTO THE DEATHS OF
STAR ELLEN BORLASE, JACK MORLEY BORLASE, HELEN KALD CASTLE, JUDITH MAUD GRIFFITH, JODY MARIA KAY, GRAHAM JOSEPH RUSSELL, ZOE RUSSELL-KAY, TRENT ALAN MURNANE AND NEIL GEORGE RICHARDSON
Finding of Inquest - Cause of Death
Executive Summary and Conclusions
Inquest conducted by Mr Anthony E Schapel, Deputy State Coroner, South Australia
CORONERS ACT, 2003
SOUTH AUSTRALIA
FINDING OF INQUEST
An Inquest taken on behalf of our Sovereign Lady the Queen at
Adelaide and Port Lincoln in the State of South Australia, from the 5th day of October 2005 to
the 8th day of May 2007 and the 18th day of December 20071, by the Coroner’s Court of the
said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the deaths of
Neil George Richardson, Trent Alan Murnane, Star Ellen Borlase, Jack Morley Borlase,
Judith Maud Griffith, Jody Maria Kay, Graham Joseph Russell, Zoe Russell-Kay and Helen
Kald Castle.
The said Court finds that Neil George Richardson aged 54 years, late
of Section 103, Hundred of Stokes, Tumby Bay, South Australia, died on Settlers Road
near Wanilla, South Australia on the 11th day of January 2005 as a result of incineration.
The said Court finds that Trent Alan Murnane aged 30 years, late of 13
O’Malley Street, Cummins, South Australia, died on Settlers Road near Wanilla, South
Australia on the 11th day of January 2005 as a result of incineration.
The said Court finds that Star Ellen Borlase aged 3 years, late of
Borlase Road, Wanilla, South Australia, died on Borlase Road near Wanilla, South
Australia on the 11th day of January 2005 as a result of incineration.
1 Refer to Annexure E for a complete listing of Court sitting days The said Court finds that Jack Morley Borlase aged 2 years, late of
Borlase Road, Wanilla, South Australia, died on Borlase Road near Wanilla, South
Australia on the 11th day of January 2005 as a result of incineration.
The said Court finds that Judith Maud Griffith aged 59 years, late of
10 Edgar Street, Bedford Park, South Australia, died on Borlase Road near Wanilla,
South Australia on the 11th day of January 2005 as a result of inhalation of products of combustion.
The said Court finds that Jody Maria Kay aged 33 years, late of Lot
92, Hundred of Poonindie, via North Shields, South Australia, died at Poonindie, South
Australia on the 11th day of January 2005 as a result of a ruptured heart due to blunt chest trauma.
The said Court finds that Graham Joseph Russell aged 13 years, late of Lot 92, Hundred of Poonindie, via North Shields, South Australia, died at Poonindie,
South Australia on the 11th day of January 2005 as a result of multiple injuries.
The said Court finds that Zoe Russell-Kay aged 11 years, late of Lot
92, Hundred of Poonindie, via North Shields, South Australia, died at Poonindie, South
Australia on the 11th day of January 2005 as a result of an undetermined cause.
The said Court finds that Helen Kald Castle aged 57 years, late of 20
Dorward Street, North Shields, South Australia, died at North Shields, South Australia on the 11th day of January 2005 as a result of the combined effects of inhalation of products of combustion and hyperthermia. EXECUTIVE SUMMARY AND CONCLUSIONS
1. Shortly after 3pm on Monday, 10 January 2005 a fire ignited in roadside vegetation on the eastern side of Lady Franklyn Road approximately 45 kilometres north-west of Port Lincoln on the Lower Eyre Peninsula.
2. A number of members of the public who resided or were working in locations approximate to the fire witnessed smoke rising from the Lady Franklyn Road location. One of those persons was a Mr Steven Nettle who resided at Wangary and who was at that time the Captain of the Wangary CFS Brigade. Mr Nettle telephoned the CFS at approximately 3:20pm to advise them of his sighting of smoke.
3. Mr Marco Visic a resident of Port Lincoln had, a little time before the smoke from the Wangary fire was detected, parked his Toyota diesel 4WD motor vehicle on the eastern side of Lady Franklyn Road. Mr Visic had alighted from his vehicle and walked into a paddock on the eastern side of Lady Franklyn Road to inspect a pile of rocks that had excited his attention. Mr Visic had been in the general area that afternoon prospecting with a metal detector.
4. At the time Mr Visic’s vehicle was parked on the eastern side of Lady Franklyn Road, the weather conditions were hot and dry and there was a wind in existence. At the time Mr Visic’s vehicle was situated on the eastern side of Lady Franklyn Road, there was no other activity of any kind at that location.
5. Mr Visic was to also advise the CFS of the existence of a fire on the eastern side of Lady Franklyn Road. He did this from a payphone at the Wangary Store at 3:29pm.
6. Mr Visic returned to the scene of the fire having made that call and encountered a Mr Thring and Mr Trevor Puckridge who had been engaged in shearing at Mr Puckridge’s property further north on Lady Franklyn Road. Mr Visic made utterances at that stage from which it can be concluded that Mr Visic entertained the firm belief that his activities on the eastern side of Lady Franklyn Road had caused the ignition of the fire.
7. Having considered very carefully all of the evidence that has been adduced during the course of this Inquest as to the circumstances in which this fire started, I am firmly of the conclusion that the source of ignition for the fire on the eastern side of Lady Franklyn Road was Mr Visic’s Toyota vehicle. I am satisfied that a carbonaceous particle or
2
particles of a sufficient size and temperature to ignite dry vegetation were emitted from the exhaust system of Mr Visic’s vehicle. I am further satisfied that the carbonaceous particle or particles landed in dry vegetation at the side of Lady Franklyn Road and immediately, or virtually immediately, ignited that vegetation.
8. Mr Visic’s exhaust system had a number of irregularities and defects that consisted of holes and imperfect joins in the system. Fitted to the Toyota vehicle was a muffler that was not a standard part for that vehicle. Compared to the standard muffler that would normally be fitted to a vehicle of that type, the non-standard after-market muffler had a lesser capacity to inhibit the passage of hot carbonaceous particles through it.
9. A hot carbonaceous particle of sufficient size could either have been emitted through the tail pipe of the vehicle having passed through the muffler, or been emitted through one of the defects in the exhaust system as a whole. I think it more probable that the hot carbonaceous particle that set fire to the vegetation on the eastern side of Lady Franklyn Road was emitted through the tail pipe having passed through the entire exhaust system including the after-market muffler.
10. After the fire was detected, a number of members of the public attended. These included farmers who had seen the smoke from a distance and who had travelled to the location in their farm firefighting appliances.
11. As well, a number of CFS appliances and their crews were despatched to the location.
12. The fire proved difficult to quell under the influence of a strong breeze. Valiant efforts were made to contain the fire during the course of the afternoon. Further CFS appliances were brought to bear on the problem. It became obvious fairly quickly that sourcing water in this general area was a problem.
13. A Mr James Casanova who had been approaching the scene along Duck Lake Road, also noticed the smoke. Mr Casanova was driving a SAME tractor with a square bulldozer blade. Mr Casanova attended at the fire scene and during the course of the afternoon cut a number of bare earth breaks in the trees at the junction of Duck Lake Road and Yorkies Gully Road and in the stubble paddocks on the property to the north of Yorkies Gully Road. 3
14. The fire proceeded in a generally east or north-easterly direction throughout the course of the afternoon and it quickly ignited trees in a large stand of sugar gums at the junction of Duck Lake Road and Yorkies Gully Road. The fire that ignited the trees at that location proved very difficult to quell during the course of the rest of the daylight hours of Monday, 10 January 2005 and overnight. Continuous efforts were made by both farmers and CFS crews to contain the fire within the sugar gum stand.
15. At some time during the course of the Monday afternoon fire traversed the stubble paddocks in an easterly direction from Duck Lake Road across the properties of Christopher Hull and Mr Siegert into a paperbark swamp that was to the north of Yorkies Gully Road and to the west of Settlers Road. The swamp was situated on the property of Messrs George and Les Hull. This property was situated north of Warunda Road. The swamp crossed Warunda Road into the property of Mr Peter Cabot. Mr Cabot maintained stubble paddocks to the west of Settlers Road and to the north of Yorkies Gully Road. For the purposes of the Inquest, and for the purposes of my findings and summary, those paddocks have been referred to as Area A and Area C as depicted on aerial imagery of the location. Mr Cabot’s homestead was situated in the north-western quadrant of the intersection of Settlers Road and Yorkies Gully Road. At the western extremity of Mr Cabot’s property a hundred line formed the boundary with the property of Christopher Hull. The swamp continued to cut across Christopher Hull’s property until it crossed Yorkies Gully Road at a culvert which was known as Yorkies Crossing.
16. The fire that burnt into the swamp penetrated it from its north-western side on the Monday afternoon and evening but did not come through to the south-eastern side.
17. Mr Robert Chambers was the recently elected Group Officer for the CFS Lower Eyre Peninsula Group. His Deputy Group Officers were Mr Robert Maddern, Mr Jeffrey Lock and Mr Russell Branson. Messrs Chambers and Branson attended the fireground on the Monday afternoon. Mr Chambers was in possession of one of the Lower Eyre Peninsula Group’s CFS 4WD command vehicles. Ultimately Messrs Chambers and Branson were joined by other members of the CFS and a Forward Command Post was, for the time being, established at a group of sheds on Christopher Hull’s property north of Yorkies Gully Road. That area became known in the Inquest as Christopher Hull’s 4
hayshed. In due course Mr Jeffrey Lock, another Deputy Group Officer, attended the scene.
18. Messrs Branson and Lock attempted to circumnavigate the fireground in order to survey it, to identify its boundaries and for the purposes of sectorisation. It had become evident that the fireground was of a significant size and that it extended as far as the property of Messrs George and Les Hull to the north of Warunda Road. Messrs Branson and Lock did not complete their circumnavigation of the fireground because Mr Chambers demanded that they return the CFS command vehicle to the hayshed. It was evident from their circumnavigation of the fireground, albeit truncated, that significant fire had penetrated the paperbark swamp at locations to the west of Area A on Mr Cabot’s property.
19. Fire had also penetrated the swamp north of Warunda Road into Messrs George and Les Hull’s property and it had also penetrated the swamp in the location where it exists on the property of Christopher Hull.
20. Areas A and C on Mr Cabot’s property and to a lesser extent on Christopher Hull’s property largely remained unattended by firefighting resources during the course of the Monday afternoon and evening and overnight into the Tuesday morning. There was some firefighting activity conducted in the early hours of the morning in the swamp to the north of Area C and in the vicinity of the hundred line that divided Mr Cabot’s property from Christopher Hull’s.
21. Mr Chambers declared the fire contained at 8:54pm on the Monday evening. By then the unfavourable weather conditions for firefighting had abated. The fact that the fire was said to be contained carried no implication that the fire was extinguished. In fact the fire was still active in the sugar gums and in the swamp.
22. During the course of the afternoon on the Monday, volunteers at the CFS base at Port Lincoln (Lincoln Base) and paid staff of CFS Region 6 Headquarters situated in Port Lincoln were having difficulty in obtaining information from the fireground, particularly in relation to fire progression, location and size. Mr Simon Vogel was on that day the Regional Duty Officer for Region 6. Ms Sonia Post, another CFS Regional Officer, was also on duty that day in Port Lincoln. The Regional Commander, Mr Neil Ellis, was in 5
Adelaide attending a meeting at CFS State Headquarters. Attending the same meeting was Mr Robert Maddern, the Lower Eyre Peninsula Deputy Group Officer 1. Mr Maddern had left the second CFS command 4WD vehicle at the airport.
23. Mr Ellis remained in Adelaide overnight. Mr Maddern returned to Port Lincoln early on the Monday night and proceeded to Region 6 Headquarters. There he was asked by Mr Vogel to go to the fireground and seek information and ensure that a proper incident management structure had been put in place. At about the same time it was decided that the hall at Wanilla would be used as an Incident Control Centre. Also at around that time, initiatives were taken to engage a relief Incident Management Team to take over from Messrs Chambers and his colleagues later that night. A Ms Angela Whillas, who was the Greenpatch CFS Brigade Captain, was chosen as the Incident Controller for the overnight shift.
24. Ms Sonia Post and Mr Maddern travelled out to the Wanilla Hall. Ms Post set up the hall as an Incident Control Centre. Mr Maddern proceeded to Christopher Hull’s hayshed where he advised those present, including Messrs Chambers, Lock and Branson and a number of police officers, that the Incident Management Team would be moving to Wanilla Hall.
25. Following that, Mr Maddern and the other gentlemen proceeded to the Wanilla Hall where an incident management structure was set up.
26. Meanwhile Mr Peter Cabot and his son-in-law, Mr Treloar, conducted a backburning operation on the edge of the swamp to the north of Area C.
27. Mr Cabot’s backburn was conducted without the approval, assistance or knowledge of the CFS. Mr Cabot conducted the backburn because he believed that with the weather conditions forecast for the Tuesday morning the fire would come out of the swamp and proceed into the stubble paddocks to the south in Area C. Mr Cabot essentially wanted to eliminate as much flammable material at the edge of the swamp as he could. Mr Cabot did not conduct any backburning in Area A because of the presence of canola stubble on the edge of that swamp. Canola stubble is difficult to light but once alight is very flammable. He also did not have the resources to manage a backburning operation on that section of his property. 6
28. The backburn that Mr Cabot conducted on the edge of the swamp at Area C penetrated the swamp. Mr Cabot and Mr Treloar believed that after they had conducted the backburn the fire that they had lit had been completely extinguished and that the area was safe.
29. Mr Cabot did not have any contact with the CFS on the Monday night.
30. The weather forecast for the Tuesday morning was very unfavourable for firefighting. The forecast was the subject of a CFS and Bureau of Meteorology joint teleconference on the Monday afternoon. At that teleconference the weather was described in terms that suggested that the Tuesday was going to be, for the whole of the State, a very difficult day for firefighting. Total fire bans for the whole of the State were put in place. A weather forecast obtained in relation to the fireground late on Monday afternoon suggested that there would be very high temperatures on the Tuesday and strong north- north-westerly winds in the morning. This would naturally prove problematic for firefighting, particularly in an existing fireground that had a south-eastern perimeter in relatively inaccessible swamp country. During the course of the night, the very unfavourable weather forecast was confirmed. The forecast suggested that there would be extreme conditions existing at 10am. Also predicted was a westerly change in the course of the late morning, early afternoon. That change would also not be favourable for firefighting and would put any person on the eastern flank of a running fire in great danger on the change of the wind.
31. At Wanilla Hall Mr Lock plotted the fireground on a map. It was clearly understood that there was fire in the swamp along its length from Warunda Road to the south-west.
32. At Wanilla Hall Mr Chambers articulated an Incident Action Plan that was not reduced to writing but which was that the fireground would be blacked out to a distance of 30 metres. This was subsequently altered to a distance of 60 metres at some point in time.
33. The fireground was sectorised into a number of sectors. The relevant sectors for the swamp were the Swampy Sector and the Yorkies Crossing Sector. The Swampy Sector at first encompassed that part of the swamp north of Warunda Road on the property of Messrs George and Les Hull, but did not encompass Area A or the swamp to the west of Area A in Mr Cabot’s property. The Yorkies Crossing Sector encompassed the fire 7
perimeter north of Area C on Mr Cabot’s property and on Christopher Hull’s property. This meant that there was a gap in the sectorisation of the fireground which consisted of Area A and the swamp to the west of Area A. A Sector Commander was appointed for the Swampy Sector and a Sector Commander was not appointed for the Yorkies Crossing Sector. In due course the boundary of the Swampy Sector was extended to encompass Area A and the swamp to the west of it. However, this extension was not communicated to the Sector Commander either for the first shift or the second shift being the overnight shift.
34. When Mr Chambers devised the Incident Action Plan to black out, he had not examined the fireground.
35. No other containment measures for the south-eastern perimeter through the swamp were devised. Other than Mr Cabot’s backburn there was no other backburning operation conducted on the south-eastern perimeter of the fire. Nor were any bare earth fire breaks created in the stubble paddocks to the east and south of the swamp, either in Mr Cabot’s property or Christopher Hull’s property.
36. No aerial firefighting resources were sought or organised for the Tuesday morning to guard against the eventuality that the fire might flare-up and break away from the swamp under the influence of the predicted strong north-north-westerly wind.
37. Neither Area A, nor the swamp to the west of Area A, were attended by the CFS during the course of the Monday night and Tuesday morning. It is to be inferred that one reason for that was the fact that the Sector Commander for that area was unaware of his responsibility in relation to it. In any event, no containment work was implemented in the paddocks of Area A nor in the swamp itself to the west of that area and that remained the position until a breakout of fire eventually occurred there on the Tuesday morning.
38. As far as Area C was concerned, no appliances attended in that location or the swamp to the north until about 3:30am on the Tuesday morning. Christopher Hull had requested the presence of an appliance in the vicinity of the hundred line. Blacking out work took place there. Mr Branson also arranged for CFS attendance at the site where Mr Cabot had backburnt. The Karkoo appliance performed blacking out operations on the edge of the swamp at that location. 8
39. Without any other supporting containment measures and without detailed information as to the nature and accessibility of the terrain in the swamp, the plan to black out was a facile solution to a complex problem. The plan was flawed in its execution. No resources were applied to one of the most vulnerable areas (Area C) until the early hours of the Tuesday morning. In the other very vulnerable location (Area A), no resources were in place at all.
40. In addition, there was an imperfect assessment of risk at the time the Incident Action Plan was devised. It failed to take into account the very grave risks posed by the weather forecast for the Tuesday morning.
41. For some reason for which there is no clear explanation, Mr Chambers left the Wanilla Hall that night at a time before the oncoming Incident Controller, Ms Whillas, arrived. When Mr Chambers left Wanilla Hall this left the Incident Management Team without an Incident Controller for a substantial period of time. Mr Maddern, although a very experienced firefighter and incident manager, did not regard himself as a member of the Incident Management Team except in a minor capacity as a scribe. There was confusion as well about the role of Mr Lock.
42. Ms Post, a paid officer of the CFS, had been advised by Mr Vogel, the Regional Duty Officer, not to become involved in incident management issues. She therefore gained a very limited understanding of the situation as it applied to the fire and did not in any sense scrutinise or validate the Incident Management Team’s plan of containment.
43. Ms Whillas, the Greenpatch Brigade Captain and incoming Incident Controller for the overnight shift, had participated in an incident management course in 2004. She had no experience in the management of an incident of this complexity. Her incident management experience was limited to incidents involving only a few appliances. To my mind Ms Whillas’ appointment as the Incident Controller for the overnight shift on this large and complex fireground was not appropriate. Mr Branson continued in his role as the Operations Officer.
44. Ms Whillas remained at Wanilla Hall overnight. Her knowledge of the fireground was very limited. Any risk assessment that she performed was superficial. 9
45. Mr Branson proceeded out to the fireground where he made an inspection. In Area C he caused some appliances to conduct some work including that performed by the Karkoo appliance to which I have already referred. However, nothing was undertaken in Area A or to the west of Area A in the swamp.
46. However, much work was conducted overnight in relation to the sugar gum area that was still burning. A number of CFS appliances and farm appliances remained at that location throughout the night and blacking out and other firefighting activity took place there.
47. In the daylight hours of the Tuesday morning, a change of shift occurred and this involved the implementation of a new Incident Management Team. Mr Chambers returned as Incident Controller and Mr Maddern became the Planning Officer.
48. District Council of Lower Eyre Peninsula grader operators had left their plant and equipment at the fireground overnight. That equipment had been engaged in containment activity on the northern part of the fireground on the Monday. When the plant operators reported at Wanilla Hall on the Tuesday morning they were told their services were not required. This meant that no bare earth containment work was undertaken in the areas to the east and south of Areas A and C. I find that there was a clear opportunity for plant and equipment to have been used to create or attempt to create bare earth breaks in those locations.
49. Mr Simon Vogel had remained at Region 6 Headquarters until 1am on the Tuesday morning. Ms Post had remained at the Wanilla Hall also very late. Mr Vogel and Ms Post were back on duty early on the Tuesday morning. Ms Post travelled directly to Wanilla Hall. Mr Vogel commenced his duties at Region 6 Headquarters in Port Lincoln.
50. At 7:45am at Wanilla Hall, Mr Maddern declared that the fire was controlled. This declaration had occurred after a briefing that had been conducted by the outgoing Incident Controller, Ms Whillas, and by the outgoing Operations Officer, Mr Branson. The declaration that the fire was controlled was flawed. A declaration that a fire is controlled by definition means that the fire perimeter of a fireground is secure and that no breakaways are expected. In my opinion there was no proper foundation for any assertion that the fire perimeter was secure or that no breakaways were expected. This is 10
especially so given the severity of the weather forecast for the Tuesday morning, and the absence of any meaningful containment work to the east and south of the swamp. This meant that communities and assets to the south-east of the fireground were at risk. If that risk was appreciated by anyone on the Tuesday morning it was not articulated. In particular, the police were not alerted to that risk and no warning was given to members of the public. No measures were taken to alert possibly affected communities. Communities and individuals to the south-east of the fireground went about their daily business in ignorance of the risk. Exceptions to that state of affairs were residents very close to the fireground such as Mr Cabot, Messrs George and Les Hull and Mr Giddings who owned premises on Settlers Road known as Beaumont. This property and homestead was on the eastern side of Settlers Road and the east-south-east of Area A.
51. During the course of the Monday evening Mr Vogel had received information from the fireground via Lincoln Base. Mr Vogel had an incomplete picture as to the nature of the incident. He was taken by surprise when he learnt that the fireground had become magnified to an area of 1800 hectares with a south-eastern flank of several kilometres. Mr Vogel learnt of Mr Chambers’ declaration that the fire was contained within a few minutes of the declaration. He took it at face value. Mr Vogel did not scrutinise or validate any plan that was put in place to secure the overnight fireground. Mr Vogel had forwarded information that he was receiving from time to time to CFS State Headquarters via facsimile. None of that information, including the revelation that the fireground was 1800 hectares, was actually passed on to anyone in authority at State Headquarters that night. The Deputy State Coordinator, Mr Miller, had not received any of the faxes nor any verbal communication. The last information he had was that the fireground was of about 40 hectares and would likely be contained overnight. He had received that information at the weather teleconference on the Monday afternoon.
52. It was not until approximately 11pm that anyone at State Headquarters gained an appreciation of the size of the fireground being 1800 hectares. As a result of that realisation, junior staff at State Headquarters caused a Significant Incident page to be sent to senior CFS Officers including Mr Miller and the Chief Officer, Mr Ferguson. Mr Miller did not receive that page. Mr Ferguson received the page but believed Mr Miller would have received it and acted upon it. 11
53. If Mr Miller had received the necessary information as the fire incident was developing on the Monday night, it is very likely that steps would have been taken to address the incident at a State level. This may have resulted in important resources such as aerial water bombers being made available for the Tuesday morning. Those resources were never put in place. They were not available until well into the Tuesday after the fire had become uncontrollable.
54. On the Tuesday morning, the Incident Control Centre was moved from Wanilla Hall to the Wangary Sports Complex. This proved to be somewhat of a distraction. Mr Nettle was with the Incident Management Team. He was meant to be the Sector Commander for Yorkies Crossing Sector which incorporated Area C but had no knowledge of that. The Sector Commander for the Scrubby Sector did not know that he had responsibility for Area A.
55. No containment work was conducted on the Tuesday morning, nor were there any appliances placed in Area A in anticipation of possible breakouts. In Area C there was spasmodic attendance by CFS appliances.
56. At approximately 9:30am the weather started to deteriorate. It was hot and windy. There was a flare-up in the sugar gums that required the presence of a number of appliances.
57. At about 9:50am two farm firefighters in a utility, Messrs Andrew and Byass, observed fire creeping along the northern side of the swamp in a south-westerly direction towards the narrow part of the swamp on Christopher Hull’s property. They witnessed the fire enter the swamp a quite narrow portion and then proceed across it. The fire then entered the paddocks to the south-east of the swamp where wheat stubble caught alight. Appliances and farm units that had been at the sugar gum area attending to the flare-up were brought into that area but the fire in Christopher Hull’s paddocks could not be brought under control. At around that time fire also spread into the vegetation in the hundred line that divided Mr Cabot’s property from that of Christopher Hull. Some minutes later, fire emerged from the swamp to the east of the hundred line on Mr Cabot’s property. At that location, a large amount of spotting from the swamp proceeded into the stubble paddocks. Ultimately, the fire from the narrow of the swamp. the fire at the hundred line and the fire in the paddocks to the east of the hundred line became 12
uncontrollable. This was in spite of the very courageous efforts of CFS crew members and farmers. Fire that emanated from its various sources in Area C on Christopher Hull’s and Mr Cabot’s stubble paddocks spread uncontrolled in a south-easterly direction under a strong north-westerly wind. It proceeded across stubble paddocks to the south of Yorkies Gully Road towards the Murrunatta Conservation Park. The fire entered the park, traversed the park, crossed Settlers Road and made its way in a south-easterly direction towards the Wanilla Forest. By then the time was a little after 11:30am.
58. Mr Darren Borlase and his wife Natalie Borlase lived on Borlase Road which was just to the east of Wanilla Forest. Mr Borlase was in hospital in Port Lincoln at the time. Natalie Borlase went to work on the Tuesday morning. Her parents, Wayne and Judith Griffith, were visiting from Adelaide at that time and were looking after the Borlase children, Star and Jack. They were in the Borlase home on Borlase Road.
59. Mrs Griffith and the two children perished when they proceeded onto Borlase Road in a motor vehicle. Mr Griffith who was in a separate vehicle survived.
60. The fire that caused the deaths of Mrs Griffith and the Borlase children I find was sourced from Area C being the area encompassing both Mr Cabot’s paddocks and Christopher Hull’s paddocks to the south of the swamp.
61. At about 10:25am a large flare-up was seen to occur in the swamp to the west of Area A. When this was observed, CFS appliances were sent into Area A in an attempt to combat spotting that was emanating from the swamp. The courageous crews of those appliances unfortunately were not able to contend with the large amount of spotting and eventually a fire front emerged from the swamp that very nearly overwhelmed one of those crews. The fire spread unchecked in a south-easterly direction at first, fanned by a strong north- westerly wind. Sometime shortly after 11:30am, the wind at that location changed to a westerly. Messrs Murnane and Richardson had been at the Beaumont property on Settlers Road assisting other farmers to wet down assets at that property. Messrs Murnane and Richardson perished when they proceeded in their farm firefighting utility from the Beaumont premises onto Settlers Road. The fire that overwhelmed them I find originated from the swamp in Area A. 13
62. During the course of the morning and early afternoon fire proceeded across the landscape of the Lower Eyre Peninsula in a westerly direction. The fire was in the main carried by stubble fuels.
63. Ultimately, the fire reached North Shields on the coast. It also reached Poonindie which is a settlement on the Lincoln Highway to the north of North Shields. The source of the fire that crossed the landscape was the fire that had emanated from Area C to the south of the swamp on the properties of Mr Christopher Hull and Mr Peter Cabot.
64. Mrs Helen Castle and her husband occupied a premises on the eastern side of Dorward Road at North Shields. Mr Castle was at work on the Monday. Mrs Castle was on holidays from her job as a school teacher and was at home. Mrs Castle perished in her home at North Shields when the premises was destroyed by fire.
65. Mr and Mrs Kay lived at Hirschausen Road at Poonindie with their two children Zoe Russell-Kay and Graham Russell. Mr Damian Kay that morning had flown to Adelaide for a medical appointment. This left Mrs Jody Kay and the two children at the Hirschausen Road house.
66. Mrs Kay and her children proceeded onto the Lincoln Highway at Poonindie in their car. The vehicle was overwhelmed by smoke and it struck trees off to the side of the highway.
67. As the fire approached Wanilla Forest and then across the Lower Eyre Peninsula landscape, the CFS issued a number of phase warnings advising residents in certain locations about the approach of the fire. The approach of the fire was very rapid. Many of the phase warnings were mis-timed and not particularly appropriate for the locations to which they were directed. There was no evidence that any of the persons who lost their lives were relying on the existence of, or accuracy or otherwise, of CFS phase warnings.
68. A new phase warning system has been implemented by the CFS since this incident. The question of public warnings in a bushfire setting is a difficult one. If the risk that had existed in the uncontrolled fire within the swamp had been identified, either on the Monday night or on the Tuesday morning, there would have been a significant need for a public warning well in advance of any possible or anticipated breakout. There was a likelihood, if not inevitability, that the fire would break out of the swamp and once out of the swamp, would be uncontrollable. There was an inadequate appreciation of that risk on the Monday night or the Tuesday morning. A heightened level of vigilance by the 14
members of CFS Incident Management Teams, and Region 6 Headquarters and State Headquarters personnel may have identified that risk. If this had taken place, it would have been impossible to justify withholding information about that risk from the general public. In those circumstances a warning would have been inevitable. In the event, the community to the south-east and east of the fireground were unaware of the risk of fire in many instances until it was too late.
69. As to the suggestion that nothing would have stopped that fire, or that nothing could have been done to prevent the fire from escaping from its fireground overnight, one has to view the matter with the disadvantage of hindsight. The fact of the matter was that no adequate measures were put in place or attempted which meant that opportunities to alter the outcome were not taken. Because the risk to the public was never properly addressed or appreciated, none of those measures were ever adequately considered. For the same reason no adequate warning was given.
70. In dealing with the performance of volunteer Incident Management Teams, and that of the individual members of those teams, it has to be borne steadily in mind that one can always find fault in a setting of such complexity. The temptation to criticise the minutiae of every decision that was taken by a group of individuals or by the individuals themselves is sometimes difficult to resist. Whilst one always strives for excellence, excellence is not to be equated with absolute perfection. This is especially so in my view when one considers that many of the individuals concerned, and who have been the subject of very strident criticism, were volunteers who bestowed their time and effort on this very complex problem with no thought for their own self promotion. It has to be also considered that if there had been a favourable outcome in this fire, it is unlikely that the members of the Incident Management Teams would have been accorded accolades in any sense proportionate to the criticism that they have had to endure.